A patient is to receive whirlpool treatments for a chronic ulcer to the left heel. The nurse is aware that whirlpool treatments are a form of which type of debridement?
1. sharp debridement
2. chemical debridement
3. autolytic debridement
4. mechanical debridement
4
Rationale: Mechanical debridement is accomplished with moist dressing changes, irrigation, or whirlpool treatments. Sharp debridement is the removal of necrotic areas using a scalpel or scissors. Chemical debridement involves the use of topical enzymes that are applied to necrotic areas. Autolytic debridement involves the use of dressing materials that selectively liquefy necrotic tissue.
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On percussion of the client with abdominal trauma, the nurse identifies resonance over the right flank while the client is in a left side-lying position. What does this finding indicate?
A. The client has a fractured rib. B. The client has a ruptured spleen. C. The client has an injury to the liver. D. The client has retroperitoneal bleeding.
The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint?
1. Blood urea nitrogen 2. Hemoglobin and hematocrit 3. Blood sugar 4. Serum potassium
You are performing CPR on a patient whom you have found on the floor in an empty lounge area. No one else is in the vicinity. You should get help by
A. running for the nurse. B. calling out loudly. C. waiting for someone to find you. D. looking for a call signal or phone.
The nurse is diligent in skin care to prevent pressure ulcers because older adults are at risk because _______________________________. (Select all that apply.)
a. the epidermal layer has thickened. b. subcutaneous fat has diminished. c. bruising is prevalent. d. skin receptor cells have reduced in sensitivity. e. the skin is dry and scaly.